Request for Cancer Support

Request for Cancer Support

This request form must be completed by a health professional on behalf of, and with consent of the client.
- Health Professional Details
- Name
  
  First NameLast Name
- Occupation *
- Email*
  example@example.com
- Phone Number*
  Please enter a valid phone number.Format: (000) 000-0000.
- Health Centre/Hospital Name *
- Health Centre/Hospital Postcode*
- How did you find us?
- Has the client consented to this required for support?*
  
  YesNo
- Client Information
- I have the consent of my client to share their personal information with Cancer Council Queensland*
  
  Yes
- Name*
  
  First NameLast Name
- Gender*
- Are you of Aboriginal or Torres Strait Islander descent?
- Client's Post Code*
- Client's Country of Birth*
- Contact Details
  
  Please provide at least 2 contact details
- Home Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Mobile Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Work Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Other Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Email
  example@example.com
- Preferred time for contact
  
  MorningAfternoonAny
- Can we identify as Cancer Council Queensland when calling?*
  
  YesNo
- Is this request for a patient or a family member?*
  
  PatientFamily member
- Cancer Type*
- Date of Diagnosis
  
  MonthDayYear
  Date
- Treatment Required
  
  SurgeryChemotherapyRadiation TherapyImmunotherapyOther
- Support Requested
  
  Financial CounsellingLegal MattersEmotional and psychosocialAccomodation and transportPeer supportWig and Turban serviceGeneral cancer information and support
- Additional Information
  i.e. expected patient discharge date, treatment schedule, access requirements such as translation services or National Relay, other specific patient needs, their carer or family.
- We take privacy seriously. We are committed to respecting your privacy and protecting your personal information. For referrers, your personal information is being collected so that we may contact you about this request for cancer support if required. For Clients, your personal information is being collected so that we may contact you about your request for cancer support. For more information on how we collect and handle your personal information please see our Privacy Collection Statement.
- Do you accept the Privacy Collection Statement?*
  
  I agree to Cancer Council Queensland's Privacy Collection Statement
- As a referring health professional, do you wish to be a part of our health professional network?
  
  Click here to sign up.
- Should be Empty:

Request for Cancer Support

Health Professional Details

Client Information

Contact Details